Block 3 Flashcards
Inspection of the left ventricle reveals all except which of the following?
Papillary muscles
Trabeculae carnae
Chordae tendinae
Conus arteriosus
Openings of the venae cordis minimae
The conus arteriosus (infundibulum) is the smooth walled outflow tract of the right ventricle leading to the pulmonary trunk.
A 23 year old lady with troublesome axillary hyperhidrosis is undergoing a thorascopic sympathectomy to treat the condition. Which of the following structures will need to be divided to access the sympathetic trunk?
Intercostal vein
Intercostal artery
Parietal pleura
Visceral pleura
None of the above
The sympathetic chain lies posterior to the parietal pleura. During a thorascopic sympathetomy this structure will need to be divided. The intercostal vessels lie posteriorly. They may be damaged with troublesome bleeding but otherwise are best left alone as deliberate division will not improve surgical access
A 44 year old man undergoes a distal gastrectomy for cancer. He is slightly anaemic and therefore receives a transfusion of 4 units of packed red cells to cover both the existing anaemia and associated perioperative blood loss. He is noted to develop ECG changes that are not consistent with ischaemia. What is the most likely cause?
Hyponatraemia
Hyperkalaemia
Hypercalcaemia
Metabolic alkalosis
Hypernatraemia
The transfusion of packed red cells has been shown to increase serum potassium levels. The risk is higher with large volume transfusions and with old blood.
Treatment of hyperhidrosis possible complications
For treatment of hyperhidrosis the sympathetic denervation can be achieved by removing the second and third thoracic ganglia with their rami. Removal of T1 will cause a Horners syndrome and is therefore not performed.
In which space is a lumbar puncture performed?
Subdural space
Epidural space
Subarachnoid space
Extradural space
Intraventricular space
Samples of CSF are normally obtained by inserting a needle between the third and fourth lumbar vertebrae. The tip of the needle lies in the sub arachnoid space, the spinal cord terminates at L1 and is not at risk of injury. Clinical evidence of raised intracranial pressure is a contraindication to lumbar puncture.
A 56 year old lady with idiopathic thrombocytopenic purpura has a platelet count of 50. She is due to undergo a splenectomy. What is the optimal timing of a platelet transfusion in this case?
24 hours pre-operatively
2 hours pre-operatively
Whilst making the skin incision
After ligation of the splenic artery
On removal of the spleen
ITP causes splenic sequestration of platelets. Therefore a platelet transfusion should be carefully timed. Too soon and it will be ineffective. Too late and unnecessary bleeding will occur. The optimal time is after the splenic artery has been ligated.
Indications for splenectomy
Trauma: 1/4 are iatrogenic
Spontaneous rupture: EBV
Hypersplenism: hereditary spherocytosis or elliptocytosis etc
Malignancy: lymphoma or leukaemia
Splenic cysts, hydatid cysts, splenic abscesses
Post-splencetomy changes
Platelets will rise first (therefore in ITP should be given after splenic artery clamped)
Blood film will change over following weeks, Howell Jolly bodies will appear
Other blood film changes include target cells and Pappenheimer bodies
Increased risk of post splenectomy sepsis, therefore prophylactic antibiotics and pneumococcal vaccine should be given.
Epidemiology of colonoscopy
5 out of 10 will have a normal exam
4 out of 10 will have polyps
1 out of 10 will have cancer
What patients need referral for colonoscopy
- Altered bowel habit for more than six weeks
- New onset of rectal bleeding
- Symptoms of tenesmus
A 21 year old man is stabbed in the antecubital fossa. A decision is made to surgically explore the wound. At operation the surgeon dissects down onto the brachial artery. A nerve is identified medially, which nerve is it likely to be?
Radial
Recurrent branch of median
Anterior interosseous
Ulnar
Median
Median
Most common primary liver tumours
Cholangiocarcinoma and HCC.
Metastatic disease accounts for 95% of all liver malignancies
Diagnosis of HCC
CT/MRI
AFP
Biopsy should be avoided as it seeds tumour cells.
In diagnostic uncertainty, serial CT and aFP measurents are prefered
Staging of HCC
Liver MRI, CT CAP
Use of PET CT in HCC
Can be used to identify occult nodal disease
Treatment of HCC
Surgical resection is the mainstay of treatment in operable cases. In patients with a small primary tumour in a cirrhotic liver whose primary disease process is controlled, consideration may be given to primary whole liver resection and transplantation.
Liver resections are an option but since most cases occur in an already diseased liver the operative risks and post-operative hepatic dysfunction are far greater than is seen following metastectomy.
These tumours are not particularly chemo or radiosensitive however, both may be used in a palliative setting. Tumour ablation is a more popular strategy.
Survival in HCC
15% at 5 years
Tumour markers in cholangiocarcinoma
CA 19-9, CEA and CA 125 are often elevated
Diagnosis of cholangiocarcinoma
Patients will typically have an obstructive picture on liver function tests.
CA 19-9, CEA and CA 125 are often elevated
CT/ MRI and MRCP are the imaging methods of choice.
Treatment of cholangiocarcinoma
Surgical resection offers the best chance of cure. Local invasion of peri hilar tumours is a particular problem and this coupled with lobar atrophy will often contra indicate surgical resection.
Palliation of jaundice is important, although metallic stents should be avoided in those considered for resection.
Survival in cholangiocarcinoma
5-10% 5ys
A 56 year old man has long standing chronic pancreatitis and develops pancreatic insufficiency. Which of the following will be absorbed normally?
Fat
Protein
Folic acid
Vitamin B12
None of the above
Pancreatic lipase is required for digestion of fat, Proteases facilitate protein and B12 absorption. Folate digestion is independent of the pancreas.
Rate of pancreatic secretions
1000-1500mL per 24 hours
pH 8
Substances secreted by acinar cells of the pancreas
Trypsinogen
Procarboxylase
Amylase
Elastase
Activation of trypsin
Trypsinogen is converted via enterokinase to active trypsin in the duodenum. Trypsin then activates the other inactive enzymes
A 65 year old man with long standing atrial fibrillation develops an embolus to the lower leg. The decision is made to perform an embolectomy, utilising a trans popliteal approach. After incising the deep fascia, which of the following structures will the surgeons encounter first on exploring the central region of the popliteal fossa?
Popliteal vein
Common peroneal nerve
Popliteal artery
Tibial nerve
None of the above
The tibial nerve lies superior to the vessels in the inferior aspect of the popliteal fossa. In the upper part of the fossa the tibial nerve lies lateral to the vessels, it then passes superficial to them to lie medially. The popliteal artery is the deepest structure in the popliteal fossa.
Theme: Gastrointestinal bleeding
A.Haemorrhoids
B.Meckels diverticulum
C.Angiodysplasia
D.Colonic cancer
E.Diverticular bleed
F.Ulcerative colitis
G.Ischaemic colitis
Please select the most likely cause of colonic bleeding for the scenario given. Each option may be used once, more than once or not at all
A 73 year old lady is admitted with a brisk rectal bleed. She is otherwise well and the bleed settles. On examination her abdomen is soft and non tender. Elective colonoscopy shows a small erythematous lesion in the right colon, but no other abnormality.
A 23 year old man complains of passing bright red blood rectally. It has been occurring over the past week and tends to occur post defecation. He also suffers from pruritus ani.
A 63 year old man presents with episodic rectal bleeding the blood tends to be dark in colour and may be mixed with stool. His bowel habit has been erratic since an abdominal aortic aneurysm repair 6 weeks previously.
The correct answer is Angiodysplasia
Angiodysplasia can be difficult to identify and treat. The colonoscopic stigmata are easily missed by poor bowel preparation.
Haemorrhoids
Classical haemorrhoidal symptoms include bright red rectal bleeding, it typically occurs post defecation and is noticed on the toilet paper and in the toilet pan. It is usually painless, however, thrombosed external haemorrhoids may be very painful.
Ischaemic colitis
The inferior mesenteric artery may have been ligated and being an arteriopath collateral flow through the marginal may be imperfect.
Why does colonic bleeding rarely present as malaena?
This typically presents as bright red or dark red blood per rectum. Colonic bleeding rarely presents as malaena type stool, this is because blood in the colon has a powerful laxative effect and is rarely retained long enough for transformation to occur and because the digestive enzymes present in the small bowel are not present in the colon. Up to 15% of patients presenting with haemochezia will have an upper gastrointestinal source of haemorrhage.
Bleeding may be brisk in advanced cases, diarrhoea is commonly present. Abdominal x-ray may show featureless colon.
Colitis
Acute diverticulitis often is not complicated by major bleeding and diverticular bleeds often occur sporadically. 75% all will cease spontaneously within 24-48 hours. Bleeding is often dark and of large volume.
Diverticular disease
Colonic cancers often bleed and for many patients this may be the first sign of the disease. Major bleeding from early lesions is uncommon
Cancer
Typically bright red bleeding occurring post defecation. Although patients may give graphic descriptions bleeding of sufficient volume to cause haemodynamic compromise is rare.
Haemorrhoidal bleeding
Apart from bleeding, which may be massive, these arteriovenous lesions cause little in the way of symptoms. The right side of the colon is more commonly affected.
Angiodysplasia
Management of lower GI bleed
Supportive with correction of any haemodynamic compromise
When haemorrhoidal bleeding is suspected a proctosigmoidoscopy is reasonable as attempts at full colonoscopy are usually time consuming and often futile.
In the unstable patient the usual procedure would be an angiogram (either CT or percutaneous), when these are performed during a period of haemodynamic instability they may show a bleeding point and may be the only way of identifying a patch of angiodysplasia.
In others who are more stable the standard procedure would be a colonoscopy in the elective setting. In patients undergoing angiography attempts can be made to address the lesion in question such as coiling. Otherwise surgery will be necessary.
In patients with ulcerative colitis who have significant haemorrhage the standard approach would be a sub total colectomy, particularly if medical management has already been tried and is not effective.
Indications for surgery in lower GI bleed
Patients > 60 years
Continued bleeding despite endoscopic intervention
Recurrent bleeding
Known cardiovascular disease with poor response to hypotension
Surgical management of lower GI bleed
Selective mesenteric embolisation if life threatening bleeding. This is most helpful if conducted during a period of relative haemodynamic instability. If all haemodynamic parameters are normal then the bleeding is most likely to have stopped and any angiography normal in appearance. In many units a CT angiogram will replace selective angiography but the same caveats will apply.
If the source of colonic bleeding is unclear; perform a laparotomy, on table colonic lavage and following this attempt a resection. A blind sub total colectomy is most unwise, for example bleeding from an small bowel arterio-venous malformation will not be treated by this manoeuvre.
A 39 year old man has suffered from terminal ileal Crohns disease for the past 20 years. Which condition is he least likely to develop?
Gallstones
Malabsorption
Pyoderma gangrenosum
Amyloidosis
Feltys syndrome
Felteys syndrome:
Rheumatoid disease
Splenomegaly
Neutropenia
Feltys syndrome is associated with rheumatoid disease. Individuals with long standing Crohns disease are at risk of gallstones because of impairment of the enterohepatic recycling of bile salts. Formation of entero-enteric fistulation may produce malabsorption. Amyloidosis may complicate chronic inflammatory states.
Commonest disease pattern in Crohns
The commonest disease pattern in Crohns is stricturing terminal ileal disease and this often culminates in an ileocaecal resection.
A 56 year old male presents to the acute surgical take with severe abdominal pain. He is normally fit and well. He has no malignancy. The biochemistry laboratory contacts the ward urgently, his corrected calcium result is 3.6 mmol/l. What is the medication of choice to treat this abnormality?
IV Pamidronate
Oral Alendronate
Dexamethasone
Vitamin D
Resonium salts
IV Pamidronate is the drug of choice as it most effective and has long lasting effects. Calcitonin would need to be given with another agent, to ensure that the hypercalcaemia is treated once its short term effects wear off. IV zoledronate is preferred in scenarios associated with malignancy.
Management of hypercalcaemia
ABC
IV fluid resuscitation wiht 3-6L NS in 24 hours
Concurrent administration of calcitonin
Medical therapy (usually if corrected calcium >3.0mmol/l)
When is urgent management of hypercalcaemia indicated?
Ca >3.5
Reduced consciousness
Severe abdo pain
Pre renal failure
A 53 year old man is undergoing a distal pancreatectomy for trauma. Which of the following vessels is responsible for the arterial supply to the tail of the pancreas?
Splenic artery
Pancreaticoduodenal artery
Gastric artery
Hepatic artery
Superior mesenteric artery
Pancreatic head is supplied by the pancreaticoduodenal artery
Pancreatic tail is supplied by branches of the splenic artery
There is an arterial watershed in the supply between the head and tail of the pancreas. The head is supplied by the pancreaticoduodenal artery and the tail is supplied by branches of the splenic artery.
Venous drainage of the pancreas
Head: superior mesenteric vein
Body and tail: splenic vein
A 43 year old lady presents with varicose veins and undergoes a saphenofemoral disconnection, long saphenous vein stripping to the ankle and isolated hook phlebectomies. Post operatively she notices an area of numbness superior to her ankle. What is the most likely cause for this?
Sural nerve injury
Femoral nerve injury
Saphenous nerve injury
Common peroneal nerve injury
Superficial peroneal nerve injury
The sural nerve is related to the short saphenous vein. The saphenous nerve is related to the long saphenous vein below the knee and for this reason full length stripping of the vein is no longer advocated.
Course of the long saphenous
1st digit where the dorsal vein merges with the dorsal venous arch of the foot.
Passes anterior to the medial malleolus and runs up the medial side of the leg.
At the knee it runs over the posterior border of the medial epicondyle of the femur.
Passes laterally to lie on the anterior surface of the thigh before entering the saphenous opening in the fascia lata.
Joins the femoral vein in the femoral triangle at the SFJ
Tributaries of the saphenous vein
Medial marginal
Superficial epigastric
Superficial iliac circumflex
Superficial external pudendal veins
Theme: Parasitic infections
A.Giardia Infection
B.Cryptosporidium infection
C.Clonorchis sinensis infection
D.Ancylostoma duodenale infection
E.Ascaris lumbricoides infection
F.Echinococcus granulosus infection
G.Enterobius vermicularis infection
Please select the most likely infective organism for the scenario given. Each option may be used once, more than once or not at all.
3.A 6 year old boy presents with symptoms of recurrent pruritus ani. On examination there is evidence of a small worm like structure protruding from the anus.
A 58 year old man is reviewed in the clinic following a successful cadaveric renal transplant the previous year. He has been able to return to work as a swimming instructor. Over the past week he reports that he has been suffering from recurrent episodes of diarrhoea. It has made him feel lethargic and exhausted. Stool microscopy shows evidence of cysts.
A 25 year old man returns from a backpacking holiday in India. He presents with symptoms of coughing and also of episodic abdominal discomfort. Peri anal examination is normal. Stool microscopy demonstrates both worms and eggs within the faeces.
The correct answer is Enterobius vermicularis infection
Infection with enterobius is extremely common. Pruritus is the main symptom, as there is a lack of tissue invasion it is rare for individuals to have any signs of systemic sepsis.
Cryptosporidium infection
Cryptosporidium is associated with infection, particularly in those who are immunocompromised. Diarrhoea is the main disease. The cysts are typically identified on stool microscopy.
The correct answer is Ascaris lumbricoides infection
Infection with Ascaris lumbricoides usually occurs after individuals have visited places like sub Saharan Africa or the far east. Unlike ancylostoma duodenale infection there is usually evidence of both worms and eggs in the stool. The absence of pruritus makes enterobius less likely. The presence of coughing may be due to the migration of the larva through the lungs.
Due to organism Enterobius vermicularis
Common cause of pruritus ani
Diagnosis usually made by placing scotch tape at the anus, this will trap eggs that can then be viewed microscopically
Treatment is with mebendazole
Enterobiasis
Hookworms that anchor in proximal small bowel
Most infections are asymptomatic although may cause iron deficiency anaemia
Larvae may be found in stools left at ambient temperature, otherwise infection is difficult to diagnose
Infection occurs as a result of cutaneous penetration, migrates to lungs, coughed up and then swallowed
Treatment is with mebendazole
Ancylostoma duodenale
Due to infection with roundworm Ascaris lumbricoides
Infections begin in gut following ingestion, then penetrate duodenal wall to migrate to lungs, coughed up and swallowed, cycle begins again
Diagnosis is made by identification of worm or eggs within faeces
Treatment is with mebendazole
Ascariasis
Due to infection with Strongyloides stercoralis
Rare in west
Organism is a nematode living in duodenum of host
Initial infection is via skin penetration. They then migrate to lungs and are coughed up and swallowed. Then mature in small bowel are excreted and cycle begins again
An auto infective cycle is also recognised where larvae will penetrate colonic wall
Individuals may be asymptomatic, although they may also have respiratory disease and skin lesions
Diagnosis is usually made by stool microscopy
In the UK mebendazole is used for treatment
Strongyloidiasis
Protozoal infection
Organisms produce cysts which are excreted and thereby cause new infections
Symptoms consist of diarrhoea and cramping abdominal pains. Symptoms are worse in immunosuppressed people
Cysts may be identified in stools
Treatment is with metronidazole
Cryptosporidium
Diarrhoeal infection caused by Giardia lamblia (protozoan)
Infections occur as a result of ingestion of cysts
Symptoms are usually gastrointestinal with abdominal pain, bloating and passage of soft or loose stools
Diagnosis is by serology or stool microscopy
First line treatment is with metronidazole
Giardiasis
A 23 year old women has undergone a pan proctocolectomy and ileoanal pouch because she suffers from familial adenomatous polyposis coli. What is the commonest extra colonic lesion in this disorder?
Gastric fundal polyps
Trichilemmomas
Duodenal polyps
Fibrocystic disease of the breast
Skull osteomas
Duodenal polyps occur in up to 100% of patients with FAP if follow up is continued for long enough. Duodenal cancer has an incidence of 4-10%.
Duodenal polyps are the commonest extra colonic lesion in FAP. Gastric fundal polyps are seen in 50% of patients. Skull osteomas are seen in Gardeners syndrome which is a variant of FAP.
Which of the following muscles does not attach to the radius?
Pronator quadratus
Biceps
Brachioradialis
Supinator
Brachialis
The brachialis muscle inserts into the ulna. The other muscles are all inserted onto the radius.
The oxygen-haemoglobin dissociation curve is shifted to the right in which of the following scenarios?
Hypothermia
Respiratory alkalosis
Low altitude
Decreased 2,3-DPG in transfused red cells
Chronic iron deficiency anaemia
Mnemonic to remember causes of right shift of the oxygen dissociation curve:
CADET face RIGHT
C O2
A cidosis
2,3-DPG
E xercise
T emperature
The curve is shifted to the right when there is an increased oxygen requirement by the tissue. This includes:
Increased temperature
Acidosis
Increased DPG:
DPG is found in erythrocytes and is increased during glycolysis. It binds to the Hb molecule, thereby releasing oxygen to tissues. DPG is increased in conditions associated with poor oxygen delivery to tissues, such as anaemia and high altitude.
How does hypocitraturia cause increased risk of calcium oxalate stones?
Citrate forms complexes with Ca making it more soluble
How does hyperuricosuria cause calcium oxalate stones?
Hyperuricosuria may cause uric acid stones to which calcium oxalate binds
Formation of calcium phosphate stones
May occur in renal tubular acidosis, high urinary pH increases supersaturation of urine with calcium and phosphate
Renal tubular acidosis types 1 and 3 increase risk of stone formation (types 2 and 4 do not)
Radio-opaque stones (composition similar to bone)
A pathologist is examining a histological section and identifies Hassall’s corpuscles. With what are they most commonly associated?
Follicular carcinoma of the thyroid
Medulla of the thymus
Medulla of the spleen
Medulla of the kidney
Fundus of the stomach
Hassall’s corpuscles are the concentric ring of epithelial cells seen in the medulla of the thymus.
A 25 year old man is stabbed in the upper arm. The brachial artery is lacerated at the level of the proximal humerus, and is being repaired. A nerve lying immediately lateral to the brachial artery is also lacerated. Which of the following is the nerve most likely to be?
Ulnar nerve
Median nerve
Radial nerve
Intercostobrachial nerve
Axillary nerve
The brachial artery begins at the lower border of teres major and terminates in the cubital fossa by branching into the radial and ulnar arteries. In the upper arm the median nerve lies closest to it in the lateral position. In the cubital fossa it lies medial to it.
A 63 year old man undergoes an upper GI endoscopy and adrenaline injection for a large actively bleeding duodenal ulcer. He remains stable for 6 hours and the nurses then call because he has passed 400ml malaena and has become tachycardic (pulse rate 120) and hypotensive (Bp 80/40). What is the best option?
Reassure that blood trapped in the upper portion of the gastrointestinal system will pass and that this episode will resolve with phosphate enema
Perform a repeat upper GI endoscopy
Perform a laparotomy and under-running of the ulcer
Administer tranexamic acid and intravenous proton pump inhibitors
Insert a Minnesota tube
The decision as to how best to manage patients with re-bleeding is difficult. Whilst it is tempting to offer repeat endoscopy, this intervention is best used on those with small ulcers. Large posteriorly sited duodenal ulcers are at high risk for re-bleeding and the timeframe of this event suggests that primary endoscopic haemostasis was inadequate. Surgery thus represents the safest way forward.
Small volume of fresh blood, often streaking vomit. Malaena rare. Often ceases spontaneously. Usually history of antecedent GORD type symptoms
Oesophagitis
Usually small volume of blood, except as pre terminal event with erosion of major vessels. Often associated symptoms of dysphagia and constitutional symptoms such as weight loss. May be recurrent until malignancy managed.
Cancer
Typically brisk small to moderate volume of bright red blood following bout of repeated vomiting. Malaena rare. Usually ceases spontaneously.
Mallory Weiss Tear
Usually large volume of fresh blood. Swallowed blood may cause malaena. Often associated with haemodynamic compromise. May stop spontaneously but re-bleeds are common until appropriately managed.
Varices
May be frank haematemesis or altered blood mixed with vomit. Usually prodromal features of dyspepsia and may have constitutional symptoms. Amount of bleeding variable but erosion of major vessel may produce considerable haemorrhage.
Gastric cancer
Often no prodromal features prior to haematemesis and malaena, but this arteriovenous malformation may produce quite considerable haemorrhage and may be difficult to detect endoscopically.
Dieulafoy Lesion
Usually haematemesis and epigastric discomfort. Usually there is an underlying cause such as recent NSAID usage. Large volume haemorrhage may occur with considerable haemodynamic compromise.
Diffuse erosive gastritis
Small low volume bleeds more common so would tend to present as iron deficiency anaemia. Erosion into a significant vessel may produce considerable haemorrhage and haematemesis.
Gastric ulcer
What is a consideration in haematemesis in patients with previous AAA surgery?
aorto-enteric fistulation remains a rare but important cause of major haemorrhage associated with high mortality.
Indications for surgery in UGI bleed?
Patients > 60 years
Continued bleeding despite endoscopic intervention
Recurrent bleeding
Known cardiovascular disease with poor response to hypotension
Surgical management of duodenal ulcer
Laparotomy, duodenotomy and under running of the ulcer. If bleeding is brisk then the ulcer is almost always posteriorly sited and will have invaded the gastroduodenal artery. Large bites using 0 Vicryl are taken above and below the ulcer base to occlude the vessel. The duodenotomy should be longitudinal but closed transversely to avoid stenosis.
Surgical management of gastric ulcer
Under-running of the bleeding site
Partial gastrectomy-antral ulcer
Partial gastrectomy or under running the ulcer- lesser curve ulcer (involving left gastric artery)
Total gastrectomy if bleeding persists
What can be used to stratify UGI bleed pre-endoscopy?
Blatchford score
What can be used to stratify UGI bleeds post endoscopy?
Rockall score
PPI pre-endoscopy in UGI bleed
The requirement for pre endoscopic proton pump inhibition is contentious. In the UK the National Institute of Clinical Excellence guidelines suggest the pre endoscopic PPI therapy is unnecessary. Whilst it is accepted that such treatment has no impact on mortality or morbidity a Cochrane review of this practice in 2007 did suggest that it reduced the stigmata of recent haemorrhage at endoscopy. As a result many will still administer PPI to patients prior to endoscopic intervention.
A 64 year old man presents to the clinic with right upper quadrant discomfort. He has never attended the hospital previously and is usually well. He has just retired from full time employment as a machinist in a PVC factory. CT scanning shows a large irregular tumour in the right lobe of his liver. Which of the following lesions is the most likely?
Liposarcoma
Angiosarcoma
Hamartoma
Hyatid liver disease
Benign angioma
Angiosarcoma of the liver is a rare tumour. However, it is linked to working with vinyl chloride, as in this case. Although modern factories minimise the exposure to this agent, this has not always been the case.
What is the course of the median nerve relative to the brachial artery in the upper arm?
Medial to anterior to lateral
Lateral to posterior to medial
Medial to posterior to lateral
Medial to anterior to medial
Lateral to anterior to medial
Relations of median nerve to the brachial artery:
Lateral -> Anterior -> Medial
The median nerve descends lateral to the brachial artery, it usually passes anterior to the artery to lie on its medial side. It passes deep to the bicipital aponeurosis and the median cubital vein at the elbow. It enters the forearm between the two heads of the pronator teres muscle.
A 45 year old man undergoes a sub total colectomy and formation of end ileostomy. What is the most likely sodium content per litre of ileostomy fluid?
120 mmol
60 mmol
20 mmol
210 mmol
180 mmol
Investigators in the 1960’s dehydrated and measured the sodium content of ileostomy effluent and determined this concentration. Not an experiment many would care to repeat! (120)
Which of the following muscle relaxants will tend to incite neuromuscular excitability following administration?
Atracurium
Suxamethonium
Vecuronium
Pancuronium
None of the above
Suxamethonium may induce generalised muscular contractions following administration. This may raise serum potassium levels.
Depolarising neuromuscular blocker
Inhibits action of acetylcholine at the neuromuscular junction
Degraded by plasma cholinesterase and acetylcholinesterase (affected by lack of acetylcholinesterase)
Fastest onset and shortest duration of action of all muscle relaxants
Produces generalised muscular contraction prior to paralysis
Adverse effects include hyperkalaemia, malignant hyperthermia, delayed recovery
Suxamethonium
Non depolarising neuromuscular blocking drug
Duration of action usually 30-45 minutes
Generalised histamine release on administration may produce facial flushing, tachycardia and hypotension
Not excreted by liver or kidney, broken down in tissues by hydrolysis
Reversed by neostigmine
Atracurium
Non depolarising neuromuscular blocking drug
Duration of action approximately 30 - 40 minutes
Degraded by liver and kidney and effects prolonged in organ dysfunction
Effects may be reversed by neostigmine
Vecuronium
Non depolarising neuromuscular blocker
Onset of action approximately 2-3 minutes
Duration of action up to 2 hours
Effects may be partially reversed with drugs such as neostigmine
Pancuronium
A 32 year old man is involved in a house fire and sustains extensive partial thickness burns to his torso and thigh. Two weeks post incident he develops oedema of both lower legs. The most likely cause of this is:
Iliofemoral deep vein thrombosis
Venous obstruction due to scarring
Hypoalbuminaemia
Excessive administration of intravenous fluids
None of the above
Loss of plasma proteins is the most common cause of oedema developing in this time frame.
Which of the following blood products can be administered to a non ABO matched recipient?
Whole blood
Platelets
Packed red cells
Stem cells
Cryoprecipitate
In the UK, platelets either come from pooling of the platelet component from four units of whole donated blood, called random donor platelets, or by plasmapharesis from a single donor. The platelets are suspended in 200-300 ml of plasma and may be stored for up to 4 days in the transfusion laboratory where they are continually agitated at 22oC to preserve function. One adult platelet pool raises the normal platelet count by 30,000 to 60,000 platelets litre. ABO identical or compatible platelets are preferred but not necessary in adults; but rhesus compatibility is required in recipients who are children and women of childbearing age to prevent haemolytic disease of the newborn.
Used for transfusion in chronic anaemia and cases where infusion of large volumes of fluid may result in cardiovascular compromise. Product obtained by centrifugation of whole blood.
Packed red cells
Usually administered to patients who are thrombocytopaenic and are bleeding or require surgery. It is obtained by low speed centrifugation.
Platelet rich plasma
Prepared by high speed centrifugation and administered to patients with thrombocytopaenia.
Platelet concentrate
Prepared from single units of blood.
Contains clotting factors, albumin and immunoglobulin.
Unit is usually 200 to 250ml.
Usually used in correcting clotting deficiencies in patients with hepatic synthetic failure who are due to undergo surgery.
Usual dose is 12-15ml/Kg-1.
It should not be used as first line therapy for hypovolaemia.
Fresh frozen plasma
Formed from supernatant of FFP.
Rich source of Factor VIII and fibrinogen.
Allows large concentration of factor VIII to be administered in small volume.
Cryoprecipitate
Removal of all plasma from a blood unit and substitution with:
Sodium chloride
Adenine
Anhydrous glucose
Mannitol
Up to 4 units of SAG M Blood may be administered. Thereafter whole blood is preferred. After 8 units, clotting factors and platelets should be considered.
SAG-Mannitol Blood
Which of the following is not a content of the cavernous sinus?
Oculomotor nerve
Internal carotid artery
Opthalmic nerve
Abducens nerve
Optic nerve
Mnemonic for contents of cavernous sinus:
O TOM CAT
Occulomotor nerve (III)
Trochlear nerve (IV)
Ophthalmic nerve (V1)
Maxillary nerve (V2)
Carotid artery
Abducent nerve (VI)
T
OTOM=lateral wall components
CA= components within sinus
The optic nerve lies above and outside the cavernous sinus.
Theme: Renal transplant complications
A.Acute tubular necrosis
B.Renal artery thrombosis
C.Bladder occlusion
D.Ureteric occlusion
E.Acute rejection
F.Acute on chronic rejection
G.Hyperacute rejection
For each of the scenarios given please select the most likely underlying process from the list below. Each option may be used once, more than once or not at all.
A 45 year old man with end stage renal failure undergoes a cadaveric renal transplant. The transplanted organ has a cold ischaemic time of 26 hours and a warm ischaemic time of 54 minutes. Post operatively the patient receives immunosuppressive therapy. Ten days later the patient has gained weight, becomes oliguric and feels systemically unwell. He also complains of swelling over the transplant site that is painful.
A 44 year old man with end stage renal failure undergoes a live donor renal transplant. During the immediate post operative period a good urine output is recorded. However, on return to the ward the nursing staff notice that the urinary catheter is no longer draining. However, the urostomy is continuing to drain urine.
A 43 year old man undergoes a live donor renal transplant. The donor’s right kidney is anastomosed to the recipient. On removal of the arterial clamps there is good urinary flow noted and the wounds are closed. On return to the ward the nurses notice that the patient suddenly becomes anuric and irrigation of the bladder does not improve the situation.
The correct answer is Acute rejection
The features described are those of worsening graft function and acute rejection. The fact that there is a 10 day delay goes against hyperacute rejection. Cold ischaemic times are a major factor for delayed graft function. However, even 26 hours is not incompatible with graft survival.
Bladder occlusion
The most likely explanation for this event is a blocked catheter. This may be the result of blood clot from the ureteric anastomosis. Bladder irrigation will usually resolve the problem.
The correct answer is Renal artery thrombosis
Right sided live donor transplants are extremely rare. This is because the vena cava precludes mobilisation of the right renal artery. The short right renal artery that is produced therefore presents a major challenge. The sudden cessation of urine output in this context is highly suggestive of an acute thrombosis. Delay in thrombectomy beyond 1 hour almost inevitably results in graft loss.
What are the significant technical complications of renal transplant?
Ureteric anastomosis
Warm ischaemic time (graft survival is directly related to this)
Long warm ischaemic times increase the risk of ATN.
Renal transplant
Sudden complete loss of urine output
?Renal artery thrombosis
Immediate surgery may salvage the graft, delays beyond 30 minutes are associated with a high rate of graft loss
Renal transplant
Uncontrolled hypertension, allograft dysfunction and oedema
Renal artery stenosis
Angioplasty is the treatment of choice
Renal transplant
Pain and swelling over the graft site, haematuria and oliguria
Renal vein thrombosis
The graft is usually lost
Renal transplant
Diminished urine output, rising creatinine, fever and abdominal pain
Urine leaks
USS shows perigraft collection, necrosis of ureter tip is the commonest cause and the anastomosis may need revision
Renal transplant
Common complication (occurs in 15%), may present as a mass, if large may compress ureter
Lymphocele
May be drained with percutaneous technique and sclerotherapy, or intraperitoneal drainage
A 73 year old lady is admitted for a laparoscopic cholecystectomy. During her pre-operative assessment it is noted that she is receiving furosemide for the treatment of hypertension. Where is the site of action of this diuretic?
Proximal convoluted tubule
Descending limb of the loop of Henle
Ascending limb of the loop of Henle
Distal convoluted tubule
Collecting ducts
Action of furosemide = ascending limb of the loop of Henle
Furosemide and bumetanide are loop diuretics that act by inhibiting the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle, reducing the absorption of NaCl.
MOA Frusemide
Ascending limb of loop of Henle
Na/K 2Cl
MOA thiazides
DCT and connecting segment
Na Cl carrier
MOA spironolactone
Cortical collecting tubule
Na/ K ATPase
Theme: Oesophgeal disease
A.Schatzki ring
B.Plummer Vinson syndrome
C.Squamous cell carcinoma
D.Barretts oesophagus
E.Pharyngeal pouch
F.Adenocarcinoma
G.Leiomyoma
H.Oesophageal rupture
I.Diffuse oesophageal spasm
J.Hiatus hernia
Please select the most likely underlying diagnosis for the scenario described. Each option may be used once, more than once or not at all.
A 56 year old man who drinks heavily is found collapsed by friends at his house. He was out drinking the previous night and following this was noted to have vomited repeatedly so his friends brought him home.
A 43 year old man has been troubled with dysphagia for many years. He is known to have achalasia and has had numerous dilatations. Over the past 6 weeks his dysphagia has worsened. At endoscopy a friable mass is noted in the oesophagus.
A 73 year old lady is troubled by episodic swallowing difficulty and halitosis. An upper GI endoscopy is attempted and abandoned due to difficulty in achieving intubation.
Oesophageal rupture
Spontaneous rupture of the oesophagus may occur following an episode of vomiting. The subsequent mediastinitis can produce severe sepsis and death if not treated promptly. Adequate drainage of sepsis and early surgery are the cornerstones of management.
Squamous cell carcinoma
The risk of squamous cell carcinoma of the oesophagus is increased in people with achalasia. The condition often presents late and has a poor prognosis.
The correct answer is Pharyngeal pouch
Pharyngeal pouches occur when a defect occurs in killians dehiscence. Difficulty in intubation is a well recognised consequence and care must be taken to take the correct track during OGD to avoid perforation. Most cases are now treated with endoscopic stapling.
Complete disruption of the oesophageal wall in absence of pre-existing pathology. Left postero-lateral oesophageal is commonest site (2-3cm from OG junction). Suspect in patients with severe chest pain without cardiac diagnosis and signs suggestive of pneumonia without convincing history, where there is history of vomiting. Erect CXR shows infiltrate or effusion in 90% of cases(1).
Oesophageal rupture
Surgical occlusion of which of these structures, will result in the greatest reduction in hepatic blood flow?
Portal vein
Common hepatic artery
Right hepatic artery
Coeliac axis
Left hepatic artery
The portal vein transports 70% of the blood supply to the liver, while the hepatic artery provides 30%. The portal vein contains the products of digestion. The arterial and venous blood is dispersed by sinusoids to the central veins of the liver lobules; these drain into the hepatic veins and then into the IVC. The caudate lobe drains directly into the IVC rather than into other hepatic veins.
A 43 year old man is due to undergo an excision of the sub mandibular gland. Which of the following incisions is the most appropriate for this procedure?
A transversely orientated incision 4cm below the mandible
A transversely orientated incision immediately inferior to the mandible
A vertical incision 3 cm anterior to the angle of the mandible and extending inferiorly
A transversely orientated incision 2cm above the mandible
A transversely orientated incision 12cm below the mandible
To access the sub mandibular gland a transverse incision 4cm below the mandible should be made. Incisions located higher than this may damage the marginal mandibular branch of the facial nerve.
A 55 year old man presents with symptoms of dyspepsia and on upper GI endoscopy an area of patchy erythematous tissue is identified protruding proximally from the gastro oesophageal junction. A biopsy is diagnostic of Barretts oesophagus with low grade dysplasia. Which of the following is the most appropriate management?
Distal oesophagectomy
Upper GI endoscopy with quadrantic biopsies from the region
Photodynamic therapy
Endoscopic sub mucosal resection of the area
Argon plasma coagulation
In Barrett’s surveillance the safest option is quadrantic (i.e. 4 biopsies, one from each quarter of the oesophagus at 2cm intervals)
Low grade dysplasia in conjunction with Barretts oesphagus should be monitored with regular (6 monthly) upper GI endoscopy and quadrantic biopsies. If the disease remains static at 2 years then the screening frequency may be decreased.
A 5 year old boy presents with recurrent headaches. As part of his assessment he undergoes an MRI scan of his brain. This demonstrates enlargement of the lateral and third ventricles. Where is the most likely site of obstruction?
Foramen of Luschka
Foramen of Magendie
Foramen of Munro
Aqueduct of Sylvius
None of the above
The CSF flows from the 3rd to the 4th ventricle via the Aqueduct of Sylvius.
CSF circulation
- Lateral ventricles (via foramen of Munro)
- 3rd ventricle
- Cerebral aqueduct (aqueduct of Sylvius)
- 4th ventricle (via foramina of Magendie and Luschka)
- Subarachnoid space
- Reabsorbed into the venous system via arachnoid granulations into superior sagittal sinus
Which of the following would be the optimal fluid management option for a 45 year old man due to undergo an elective right hemicolectomy?
Remain “nil by mouth” for at least 6 hours pre-operatively and avoid intra venous fluids
Remain “nil by mouth” for at least 6 hours pre-operatively and receive supplementary intravenous 5% dextrose to replace lost calories
Allow him free access to oral fluids only until 30 minutes prior to surgery
Administer a carbohydrate based loading drink 3 hours pre operatively, and avoid intravenous fluids
Administer a carbohydrate based loading drink 6 hours pre-operatively and administer 5% dextrose saline thereafter
Administer a carbohydrate based loading drink 3 hours pre operatively, and avoid intravenous fluids
Patients for elective surgery should not have solids for 6 hours pre-operatively. However, clear fluids may be given up to 2 hours pre-operatively. Enhanced recovery programmes are now the standard of care in many countries around the world and involve administration of carbohydrate loading drinks.
The routine administration of 5% dextrose in the scenarios given above would convey little in the way of benefit and increase the risks of electrolyte derangement post operatively
A 23 year old man is undergoing an inguinal hernia repair. The surgeons mobilise the spermatic cord and place it in a hernia ring. A small slender nerve is identified superior to the cord. Which nerve is it most likely to be?
Iliohypogastric nerve
Pudendal nerve
Femoral branch of the genitofemoral nerve
Ilioinguinal nerve
Obturator nerve
The ilioinguinal nerve passes through the inguinal canal and is the nerve most commonly identified during hernia surgery. The genitofemoral nerve splits into two branches, the genital branch passes through the inguinal canal within the cord structures. The femoral branch of the genitofemoral nerve enters the thigh posterior to the inguinal ligament, lateral to the femoral artery. The iliohypogastric nerve pierces the external oblique aponeurosis above the superficial inguinal ring.
Which of the following physiological changes do not occur following tracheostomy?
Alveolar ventilation is increased.
Anatomical dead space is reduced by 50%.
Work of breathing is increased.
Proportion of ciliated epithelial cells in the trachea may decrease.
Splinting of the larynx may lead to swallowing difficulties.
Work of breathing is decreased which is one reasons it is popular option for weaning ventilated patients. Humidified air in this setting helps to reduce the viscosity of mucous that forms.
Where does the spinal cord terminate in neonates?
L1
L2
L3
L4
L5
At the 3rd month the foetus’s spinal cord occupies the entire length of the vertebral canal. The vertebral column then grows longer exceeding the growth rate of the spinal cord. This results with the cord being at L3 at birth and L1-2 by adulthood.
A 45 year old man is undergoing a low anterior resection for a carcinoma of the rectum. Which of the following fascial structures will need to be divided to mobilise the mesorectum from the sacrum and coccyx?
Denonvilliers fascia
Colles fascia
Sibsons fascia
Waldeyers fascia
None of the above
Fascial layers surrounding the rectum:
Anteriorly lies the fascia of Denonvilliers
Posteriorly lies Waldeyers fascia
Waldeyers fascia separates the mesorectum from the sacrum and will need to be divided.
Theme: Gallstone disease
A.Uncomplicated biliary colic
B.Acute cholecystitis
C.Cholangitis
D.Gallbladder abscess
E.Acalculous cholecystitis
F.Pancreatitis
G.Gallstone ileus
Please select the most likely underlying diagnosis for the scenario given. Each option may be used once, more than once or not at all.
50.A 68 year old man with type 2 diabetes is admitted to hospital unwell. On examination he has features of septic shock and right upper quadrant tenderness. He is not jaundiced. Imaging shows a normal calibre bile duct and no stones in the gallbladder.
A 43 year old lady with known gallstones is admitted with a high fever and jaundice. On examination, she looks extremely unwell. Her abdomen is generally soft although there is some mild tenderness in the right upper quadrant.
A 34 year old lady is admitted with a 3 day history of colicky right upper quadrant pain which radiates to her back. The pain is now more constant. On examination she is not jaundiced, but has a temperature of 38.5oC. She has localised peritonism in the right upper quadrant.
Acalculous cholecystitis
Acalculous cholecystitis is more common in patients with an underlying co-morbidity. The morbidity and mortality following intervention are higher than in conventional gallstone disease.
Cholangitis
Features of jaundice, fever and systemic sepsis are typical of cholangitis.
Acute cholecystitis
The features of pain and fever with right upper quadrant pain are suggestive of acute cholecystitis. The short nature of the history makes an abscess less likely.
Risks of ERCP
Bleeding 0.9% (rises to 1.5% if sphincterotomy performed)
Duodenal perforation 0.4%
Cholangitis 1.1%
Pancreatitis 1.5%
A 10 year old child has a grommet inserted for a glue ear. What type of epithelium is present on the external aspect of the tympanic membrane?
Stratified squamous
Ciliated columnar
Non ciliated columnar
Non stratified squamous
None of the above
The external aspect of the tympanic membrane is lined by stratified squamous epithelium. This is significant clinically in the development of middle ear infections when this type of epithelium may migrate inside the middle ear.
Features of the external ear
Auricle is composed of elastic cartilage covered by skin. The lobule has no cartilage and contains fat and fibrous tissue.
External auditory meatus is approximately 2.5cm long.
Lateral third of the external auditory meatus is cartilaginous and the medial two thirds is bony.
The region is innervated by the greater auricular nerve. The auriculotemporal branch of the trigeminal nerve supplies most the of external auditory meatus and the lateral surface of the auricle.
Innervation of the external ear?
Greater auricular nerve.
The auriculotemporal branch of the trigeminal nervie supplies most of the external auditory meatus and the lateral surface of the auricle
Features of the middle ear
Space between the tympanic membrane and cochlea. The aditus leads to the mastoid air cells is the route through which middle ear infections may cause mastoiditis. Anteriorly the eustacian tube connects the middle ear to the naso pharynx.
The tympanic membrane consists of:
Outer layer of stratified squamous epithelium.
Middle layer of fibrous tissue.
Inner layer of mucous membrane continuous with the middle ear.
The tympanic membrane is approximately 1cm in diameter.
The chorda tympani nerve passes on the medial side of the pars flaccida.
The middle ear is innervated by the glossopharyngeal nerve and pain may radiate to the middle ear following tonsillectomy.
Innervation of the middle ear
Glossopharyngeal nerve- pain may radiate to the middle ear following tonisllectomy
What are the ossicles
Malleus attaches to the tympanic membrane (the Umbo).
Malleus articulates with the incus (synovial joint).
Incus attaches to stapes (another synovial joint).
Features of the internal ear
Cochlea, semi circular canals and vestibule
Organ of corti is the sense organ of hearing and is located on the inside of the cochlear duct on the basilar membrane.
Vestibule accommodates the utricule and the saccule. These structures contain endolymph and are surrounded by perilymph within the vestibule.
The semicircular canals lie at various angles to the petrous temporal bone. All share a common opening into the vestibule.
A 73 year old lady is admitted with acute mesenteric ischaemia. A CT angiogram is performed and a stenotic lesion is noted at the origin of the superior mesenteric artery. At which of the following levels does this branch from the aorta?
L1
L2
L3
L4
L5
The SMA leaves the aorta at L1. It passes under the neck of the pancreas prior to giving its first branch the inferior pancreatico-duodenal artery.
A 42 year old man from Southern India presents with chronic swelling of both lower legs, they are brawny and indurated with marked skin trophic changes. Which of the following organisms is the most likely origin of this disease process?
Loa loa
Wuchereria bancrofti
Trypanosoma cruzi
Trypanosoma gambiense
None of the above
W. Bancrofti is the commonest cause of filariasis leading to lymphatic obstruction. Infection with Loa loa typically occurs in the African sub continent and usually results in generalised sub cutaneous infections without lymphatic obstruction. Trypanosomal infections would not produce this clinical picture.
Parasitic filarial nematode
Accounts for 90% of cases of filariasis
Usually diagnosed by blood smears
Usually transmitted by mosquitos
Treatment is with diethylcarbamazine
Wuchereria bancrofti
The following statements relating to the musculocutaneous nerve are true except?
It arises from the lateral cord of the brachial plexus
It provides cutaneous innervation to the lateral side of the forearm
If damaged, then extension of the elbow joint will be impaired
It supplies the biceps muscle
It runs beneath biceps
It supplies biceps, brachialis and coracobrachialis. If damaged then elbow flexion rather than extension will be impaired.
Which of the following structures does not pass through the foramen ovale?
Lesser petrosal nerve
Accessory meningeal artery
Maxillary nerve
Emissary veins
Otic ganglion
Mnemonic: OVALE
O tic ganglion
V3 (Mandibular nerve:3rd branch of trigeminal)
A ccessory meningeal artery
L esser petrosal nerve
E missary veins
Which of the following is not utilised as a descriptive statistic?
Mean
Median
Mode
Z score
Standard deviation
The z score is determined using the normal distribution and is not a descriptive statistic
Which of the cranial nerves listed below is least likely to carry parasympathetic fibres?
III
VII
IX
X
II
Cranial nerves carrying parasympathetic fibres
X IX VII III (1973)
The parasympathetic functions served by the cranial nerves include:
III (oculomotor)Pupillary constriction and accommodation
VII (facial)Lacrimal gland, submandibular and sublingual glands
IX (glossopharyngeal)Parotid
X (vagus)Heart and abdominal viscera
The optic nerve carries no parasympathetic fibres.
The cranial preganglionic parasympathetic nerves arise from specific nuclei in the CNS. These synapse at one of four parasympathetic ganglia; otic, pterygopalatine, ciliary and submandibular. From these ganglia the parasympathetic nerves complete their journey to their target tissues via CN V (trigeminal) branches (ophthalmic nerve CNV branch 1, Maxillary nerve CN V branch2, mandibular nerve CN V branch 3)
Please rate this question:
A 72 year old man is undergoing an open abdominal aortic aneurysm repair. The aneurysm is located in a juxtarenal location and surgical access to the neck of aneurysm is difficult. Which of the following structures may be divided to improve access?
Cisterna chyli
Transverse colon
Left renal vein
Superior mesenteric artery
Coeliac axis
The left renal vein will be stretched over the neck of the anuerysm in this location and is not infrequently divided. This adds to the nephrotoxic insult of juxtarenal aortic surgery as a supra renal clamp is also often applied. Deliberate division of the Cisterna Chyli will not improve access and will result in a chyle leak. Division of the transverse colon will not help at all and would result in a high risk of graft infection. Division of the SMA is pointless for a juxtarenal procedure.
A 48 year old lady is being prepared for a Whipples procedure. A right sided subclavian line is inserted and then anaesthesia is induced. Following intubation the patient becomes progressively hypoxic and haemodynamically unstable. What is the most likely underlying explanation?
Drug allergy
Simple pneumothorax
Tension pneumothorax
Halothane toxicity
Haemothorax
Central lines (and particularly subclavian lines) are risk factors for the development of pneumothorax. In the context of positive pressure ventilation a tension pneumothorax is a strong possibility and would be associated with haemodynamic instability.
What is the substrate of renin?
Aldosterone
Angiotensinogen
Angiotensin converting enzyme
Angiotensin I
Angiotensin II
Renin hydrolyses angiotensinogen to form angiotensin I.
A 28 year old man is involved in a road traffic accident and sustains a flail chest injury. On arrival in the emergency department he is hypotensive. On examination; he has an elevated jugular venous pulse and auscultation of the heart reveals quiet heard sounds. What is the most likely diagnosis?
Pneumothorax
Myocardial contusion
Cardiac tamponade
Haemothorax
Ventricular septal defect
The presence of a cardiac tamponade is suggested by Becks Triad:
Hypotension
Muffled heart sounds
Raised JVP
Theme: Ankle injuries
A.Surgical fixation
B.Below knee amputation
C.Application of below knee plaster
D.Application of ankle boot
E.Application of external fixation device
F.Application of compression dressing and physiotherapy
G.Immediate reduction and application of backslab
Please select the most appropriate management for the injury type described. Each option may be used once, more than once or not at all.
A 20 year old woman trips over a step, injuring her ankle. Examination reveals tenderness over the lateral malleolus and an x-ray demonstrates an undisplaced fracture distal to the syndesmosis.
A 30 year old man injures his ankle playing football. On examination he has tenderness over both medial and lateral malleoli. X-ray demonstrates a bimalleolar fracture with a displaced distal fibula fracture, at the level of the syndesmosis and fracture of the medial malleolus with talar shift. The ankle has been provisionally reduced and splinted in the emergency department.
A 50 year old female slips on wet floor injuring her ankle. On examination, she has tenderness over the lateral and medial malleolus. X-rays demonstrate an undisplaced fracture of the distal fiibula at the level of the syndesmosis and a congruent ankle mortice.
Application of ankle boot
This is a Weber A fracture. It is a stable ankle injury and can therefore be managed conservatively. Whilst this patient could also be treated in a below knee plaster, most clinicians would nowadays treat this injury in an ankle boot. Patients should be advised to mobilise in the ankle boot, as pain allows, and can wean themselves out of the boot as the symptoms improve.
The correct answer is Surgical fixation
This is an unstable fracture pattern with a Weber B fracture of the distal fibula and a fracture of the medial malleolus. Talar shift indicates loss of ankle mortice congruity. This injury should therefore be treated with surgical fixation.
Application of below knee plaster
This is a Weber B fracture and therefore potentially unstable. Medial malleolar tenderness indicates deltoid ligament injury. As the fracture is currently undisplaced and the ankle mortice is congruent, the injury can be initially managed conservatively in a below knee plaster but the patient should be monitored in the outpatient clinic for fracture displacement in the first few weeks.
Components of the syndemosis at the ankle
The syndesmosis is a ligament complex between the distal tibia and fibula, holding the two bones together. It is fundamental to the integrity of the ankle joint, and its disruption leads to instability. It consists of (from anterior to posterior) the anterior-inferior tibiofibular ligament (AITFL), the transverse tibiofibular ligament (TTFL), the interosseous membrane, and the posterior-inferior tibiofibular ligament (PITFL).
Medial ankle ligament
Deltoid ligament. This is divided into superficial and deep portions. It is the primary restraint to valgus tilting of the talus.
Lateral ankle ligament
Lateral ligament complex consisting from anterior to posterior of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Together they resist valgus stress to the ankle, and are a restraint to anterior translation of the talus within the mortise joint.
Cardiac index=
Cardiac output/body surface area
An occlusion of the anterior cerebral artery may compromise the blood supply to the following structures except:
Medial inferior surface of the frontal lobe
Corpus callosum
Medial surface of the frontal lobe
Olfactory bulb
Brocas area
Brocas area is usually supplied by branches from the middle cerebral artery.
Ddx causes of hyperamylasaemia
Acute pancreatitis
Pancreatic pseudocyst
Mesenteric infarct
Perforated viscus
Acute cholecystitis
Diabetic ketoacidosis
Theme: Breast disease
A.Ductal carcinoma in situ
B.Lobular carcinoma in situ
C.Invasive ductal carcinoma
D.Invasive lobular carcinoma
E.Inflammatory carcinoma
F.Phyllodes tumour
G.Paget’s disease of the nipple
H.Fibroadenoma
I.Mucinous breast carcinoma
From the list please select the most likely diagnosis for the scenario given. Each diagnosis may be used once, more than once or not at all.
A 32 year old Indian lady presents with a diffuse swelling of the left breast. She has a 4 month old child. Clinically, she has jaundice and there is erythema of the left breast.
A 72 year old female presents with a painless breast lump. Clinically she has a 4cm diameter irregular breast mass, with no other palpable masses.
A 72 year old woman presents with 2 breast lumps. She has a history of breast cancer in the opposite breast 5 years ago.
Inflammatory carcinoma
Inflammatory breast cancers have an aggressive nature. Dissemination occurs early and is more resistant to adjuvent treatments than other types of breast cancer. Often occurs in pregnancy or lactation.
The correct answer is Invasive ductal carcinoma
A post menopausal woman is more likely to have a ductal carcinoma and they tend to occur at a single focus within the breast.
The correct answer is Invasive lobular carcinoma
This is likely to be an invasive lobular carcinoma, mainly due to the multifocal lesions and the history of previous breast cancer in the opposite breast.
Parasympathetic fibres innervating the parotid gland originate from which of the following?
Submandibular ganglion
Otic ganglion
Ciliary ganglion
Pterygopalatine ganglion
None of the above
Secretion of saliva by the parotid gland is controlled by nerve fibres originating in the inferior salivatory nucleus; these leave the brain via the tympanic nerve (branch of glossopharyngeal nerve (CN IX), travel through the tympanic plexus (located in the middle ear), and then form the lesser petrosal nerve until reaching the otic ganglion. After synapsing in the Otic ganglion, the postganglionic (postsynaptic) fibres travel as part of the auriculotemporal nerve (a branch of the mandibular nerve (V3) to reach the parotid gland.
Location of the parotid gland
Overlying the mandibular ramus anterior and inferior to the ear
Salivary duct of the parotid gland
Crosses the masseter, pierces the buccinator and drains adjacent to the 2nd upper molar tooth (stenson’s duct)
Following an oesophagogastrectomy the surgeons will anastomose the oesophageal remnant to the stomach, which of the following is not part of the layers that comprise the oesophageal wall?
Serosa
Adventitia
Muscularis propria
Submucosa
Mucosa
The oesophageal wall lacks the serosa layer
The wall lacks a serosa which can make the wall hold sutures less securely.
A 45 year old man is referred to the breast clinic with gynaecomastia. He takes the drugs listed below. Which is least likely to be the cause of his symptoms?
Spironolactone
Carbimazole
Chlorpromazine
Cimetidine
Methyldopa
Mnemonic for drugs causing gynaecomastia: DISCO
D igitalis
I soniazid
S pironolactone
C imetidine
O estrogen
Mnemonic for causes of gynaecomastia: METOCLOPRAMIDE
M etoclopramide
E ctopic oestrogen
T rauma skull/tumour breast, testes
O rchitis
C imetidine, Cushings
L iver cirrhosis
O besity
P araplegia
R A
A cromegaly
M ethyldopa
I soniazid
D igoxin
E thionamide
Carbimazole is not associated with gynaecomastia.
Drugs causing gynaecomastia
DISCO
D igitalis
I soniazid
S pironolactone
C imetidine
O estrogen
Causes of gynaecomastia
METOCLOPRAMIDE
M etoclopramide
E ctopic oestrogen
T rauma skull/tumour breast, testes
O rchitis
C imetidine, Cushings
L iver cirrhosis
O besity
P araplegia
R A
A cromegaly
M ethyldopa
I soniazid
D igoxin
E thionamide
Which of the following structures suspends the spinal cord in the dural sheath?
Filum terminale
Conus medullaris
Ligamentum flavum
Denticulate ligaments
Anterior longitudinal ligament
The spinal cord is approximately 45cm in men and 43cm in women. The denticulate ligament is a continuation of the pia mater (innermost covering of the spinal cord) which has intermittent lateral projections attaching the spinal cord to the dura mater.
Where is the ‘safe triangle’ for chest drain insertion located?
4th intercostal space, mid axillary line
5th intercostal space, mid axillary line
4th intercostal space, mid scapular line
5th intercostal space, mid scapular line
4th intercostal space, mid clavicular line
‘Safe Triangle’ for chest drain insertion:
5th intercostal space, mid axillary line
Borders of the safe triangle for chest drain insertion
Anterior edge latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and the apex below the axilla.
A 73 year old man develops disseminated intravascular coagulation following an abdominal aortic aneurysm repair. He receives an infusion of cryoprecipitate. What is the major constituent of this infusion?
Factor VIII
Factor IX
Protein C
Protein S
Factor V
Factor 8
Indications for cryoprecipitate
Usually massive haemorrhage/uncontrolled bleeding due to haemophilia
Composition of cryoprecipitate
Factor VIII
Fibrinogen
vWF
Factor XIII
Theme: Hand disorders
A.de Quervain’s tenosynovitis
B.Dupuytren’s contracture
C.Bouchard’s nodes
D.Ganglion
E.Carpal tunnel syndrome
F.Radial nerve injury
G.Ulnar nerve injury
H.Heberden’s nodes
I.Tendon sheath infection
Please select the most likely diagnosis to account for the scenario given. Each option may be used once, more than once or not at all.
A 49 -year-old male presents with discomfort in the fingers of his left hand. On examination, the ring and little fingers of his left hand are flexed and unable to extend completely. He is able to make a fist with the hand. Palpation reveals thickened nodules on the medial half of the palm.
A 62 year old man presents after his wife commented on the unusual shape of his fingers. On examination, he has a hard swelling adjacent to the distal interphalangeal joint of his index finger of the right hand with lateral deviation of the finger tip. There is no sensory disturbance and the swelling is not tender.
A 57 year - old lady presents with a three month history of pins and needles in the fingers of the right hand, particularly at night. On examination, there is some loss of the sensation over the palmar aspect of the lateral three fingers and wasting of the thenar eminence.
Dupuytren’s contracture
Discomfort of the hand is not uncommon in Dupuytrens contracture, true pain is unusual. The disease most commonly affects the ring and little fingers.
Heberden’s nodes
These are bony outgrowths that occur in the distal interphalangeal joint in association with osteoarthritis. They may skew the finger tip sideways. Bouchards nodes are similar, but affect the proximal interphalangeal joint.
Carpal tunnel syndrome
Carpal tunnel syndrome commonly produces pain at night as the wrists are flexed during sleep. Compromise of the median nerve may produce wasting of the thenar eminence muscles.
Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the articular cartilage
Bouchards nodes
Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the fingertip sideways. It typically affects the DIP joint.
Heberdens nodes
Osler’s nodes are painful, red, raised lesions found on the hands and feet. They are the result of the deposition of immune complexes.
Osler’s nodes
Swelling in association with a tendon sheath commonly near a joint. They are common lesions in the wrist and hand. Usually they are asymptomatic and cause little in the way of functional compromise. They are fluid filled although the fluid is similar to synovial fluid it is slightly more viscous. When the cysts are troublesome they may be excised
Ganglion
Which of the following is not characteristic of a granuloma?
Altered macrophages
Fused macrophages
Epithelioid cells
Mixture of chronic inflammatory cells
Polymorphnuclear leucocytes, cellular debris and fibrin
Polymorphnuclear leucocytes, cellular debris and fibrin
These are typical components of an abscess cavity. Polymorphonuclear leucocytes may be found in a granuloma if there is a focus of suppuration.
A 42 year old man presents with a painless lump in the left testicle that he noticed on self examination. Clinically there is a firm nodule in the left testicle, ultrasound appearances show an irregular mass lesion. His serum AFP and HCG levels are both within normal limits. What is the most likely diagnosis?
Yolk sack tumour
Seminoma
Testicular teratoma
Epididymo-orchitis
Adenomatoid tumour
Seminomas typically have normal AFP and HCG. These are usually raised in teratomas and yolk sac tumours
This man’s age, presenting symptoms and normal tumour markers make a seminoma the most likely diagnosis. Epididymo-orchitis does not produce irregular mass lesions which are painless.
Drug cause of epididymo-orchitis
Amiodarone
Theme: Large bowel obstruction
A.Ileocolic bypass
B.Loop ileostomy
C.High anterior resection
D.Insertion of self expanding metallic stent
E.Left hemicolectomy and on table colonic lavage and primary anastomosis
F.Extended right hemicolectomy and ileocolic anastomosis
G.Low anterior resection
H.Loop colostomy of the transverse colon
I.Loop colostomy of the sigmoid colon
J.Right hemicolectomy
Please select the most appropriate initial procedure for the following patients with large bowel obstruction. Each option may be used once, more than once or not at all.
A 63 year old lady presents with an obstructing cancer of the sigmoid colon. She is not peritonitic and her imaging demonstrates a solitary liver metastasis.
A 65 year old man presents with absolute constipation and abdominal pain. On examination he has marked abdominal distension. A digital rectal examination reveals an empty rectum. A rectal contrast study shows an obstructing lesion of the proximal rectum.
A 70 year old lady presents with a two day history of constipation and vomiting. On examination she has right iliac fossa tenderness and little abdominal distension. A CT scan is performed and is suggestive of an obstructing carcinoma of the colonic hepatic flexure (stage T3).
The correct answer is Insertion of self expanding metallic stent
Ideally, the distant disease should be managed first and then the primary lesion addressed. A self expanding stent is likely to achieve this and avoids a stoma.
The correct answer is Loop colostomy of the sigmoid colon
Rectal cancers should not be primarily resected prior to definitive staging and a tumour of this nature is likely to have circumferential margin involvement. Whilst a sigmoid and transverse loop colostomy would both provide an equal relief of obstruction the former procedure has the added benefit of making a subsequent resection safer, since a transverse colostomy would have to be taken down and closed during the course of subsequent surgery.
The correct answer is Right hemicolectomy
This lesion should be amenable to standard right hemicolectomy. Extending the resection to take the middle colic vessels and distal transverse colon is unlikely to provide additional oncological benefit.
Old adage in LBO
As a general rule the old adage that the sun should not rise and set on unrelieved large bowel obstruction still holds true. A caecal diameter of 12cm or more in the presence of complete obstruction with a competent ileocaecal valve and caecal tenderness is a sign of impending perforation and a relative indication for prompt surgery.
A baby is born by normal vaginal delivery at 39 weeks gestation. Initially all appears well and then the clinical staff become concerned because the baby develops recurrent episodes of cyanosis. These are worse during feeding and improve dramatically when the baby cries. The most likely underlying diagnosis is:
Choanal atresia
Oesophageal reflux
Tetralogy of Fallot
Oesophageal atresia
Congenital diaphragmatic hernia
In Choanal atresia the episodes of cyanosis are usually worst during feeding. Improvement may be seen when the baby cries as the oropharyngeal airway is used.
Congenital disorder with an incidence of 1 in 7000 births.
Posterior nasal airway occluded by soft tissue or bone.
Associated with other congenital malformations e.g. coloboma
Babies with unilateral disease may go unnoticed.
Babies with bilateral disease will present early in life as they can then only breathe through their mouth.
Treatment is with fenestration procedures designed to restore patency.
Choanal atresia
A 32 year old man presents to the acute surgical unit with acute pancreatitis. Over the next few days he becomes dyspnoeic and his saturations are 89% on air. A CXR shows bilateral pulmonary infiltrates. His CVP pressure is 16mmHg. What is the most likely diagnosis?
Cardiac failure
Pneumococcal pneumonia
Staphylococcal pneumonia
Pneumocystis carinii
Adult respiratory distress syndrome
Acute pancreatitis is known to precipitate ARDS. ARDS is characterised by bilateral pulmonary infiltrates and hypoxaemia. Note that pulmonary oedema is excluded by the CVP reading < 18mmHg.
A 28 year old lady presents with a pigmented lesion on her calf. Excisional biopsy confirms a diagnosis of melanoma measuring 1cm in diameter with a Breslow thickness of 0.1mm. The lesion is less than 1 mm at all resection margins. Which of the following surgical resection margins is acceptable for this lesion?
5 cm
1 cm
0.5 cm
2 cm
3 cm
1cm
Margins of excision related to Breslow thickness
Lesions 0-1mm thick
1cm
Margins of excision-Related to Breslow thickness
Lesions 1-2mm thick
1- 2cm (Depending upon site and pathological features)
Margins of excision-Related to Breslow thickness
Lesions 2-4mm thick
2-3 cm (Depending upon site and pathological features)
Margins of excision-Related to Breslow thickness
Lesions >4 mm thick
3cm
A 53 year old lady has undergone a bilateral breast augmentation procedure many years previously. The implants are tense and uncomfortable and are removed. During their removal the surgeon encounters a dense membrane surrounding the implants, it has a coarse granular appearance. The tissue is sent for histology and it demonstrates fibrosis with the presence of calcification. The underlying process responsible for these changes is:
Hyperplasia
Dysplasia
Metastatic calcification
Dystrophic calcification
Necrosis
Breast implants often become surrounded by a pseudocapsule and this may secondarily then be subjected to a process of dystrophic calcification.
Deposition of calcium deposits in tissues that have undergone degeneration, damage or disease in the presence of normal serum calcium levels
Dystrophic calcification
Deposition of calcium deposits in tissues that are otherwise normal in the presence of increased serum calcium levels
Metastatic calcification
A 72 year old female is found to have a malignant lesion in her left arm. She had a mastectomy of the left breast 10 years ago and has chronic lymph oedema of the left arm. What is the most likely cause of the malignancy?
Lymphangiosarcoma
Lymphoma
Myeloma
Angiomyolipoma
Giant cell tumour
Lymphangiosarcoma is a rare condition arising as a result of chronic oedema. It is an aggressive malignancy.
def: lymphoedema
Due to impaired lymphatic drainage in the presence of normal capillary function.
Lymphoedema causes the accumulation of protein rich fluid, subdermal fibrosis and dermal thickening.
Characteristically fluid is confined to the epifascial space (skin and subcutaneous tissues); muscle compartments are free of oedema. It involves the foot, unlike other forms of oedema. There may be a ‘buffalo hump’ on the dorsum of the foot and the skin cannot be pinched due to subcutaneous fibrosis.
Primary causes of lymphoedema
Congenital < 1 year: sporadic, Milroy’s disease
Onset 1-35 years: sporadic, Meige’s disease
> 35 years: Tarda
Secondary causes of lymphoedema
Bacterial/fungal/parasitic infection (filariasis)
Lymphatic malignancy
Radiotherapy to lymph nodes
Surgical resection of lymph nodes
DVT
Thrombophlebitis
Indications for surgery in lymphoedema
Marked disability or deformity from limb swelling
Lymphoedema caused by proximal lymphatic obstruction with patent distal lymphatics suitable for a lymphatic drainage procedure
Lymphocutaneous fistulae and megalymphatics
Homans procedure
For lymphoedema
Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third.
Charles operation
For lymphoedema
All skin and subcutaneous tissue around the calf are excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedure.
Lymphovenous anastamosis
For lymphoedema
Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.
Theme: Complications following renal transplant
A.Ureteric anastomotic leak
B.Renal vein thrombosis
C.Acute rejection
D.Chronic allograft nephropathy
E.Renal artery thrombosis
F.Renal artery stenosis
G.Lymphocele
H.Hyperacute rejection
For each of the patients described below, please select the most appropriate underlying explanation for the situation described. Each option may be used once, more than once or not at all.
A 45 year old lady undergoes a renal transplant from a living related donor. She is well for several months but on review in the outpatient department is noted to have persistent hypertension and a slight deterioration in renal function.
A 39 year old lady undergoes a live related renal transplant. She progresses well. Two weeks following the transplant she is noted to have swelling overlying the transplant site and swelling of the ipsilateral limb.Urine output is acceptable and creatinine unchanged.
Renal artery stenosis
Renal artery stenosis typically occurs over several months and will usually result in the development of hypertension. Most cases can be assessed using duplex scanning and managed with angioplasty.
The correct answer is Renal artery thrombosis
Sudden loss of urine output is most commonly due to a blocked catheter. However, if this is excluded (and is not included in the options) the most worrisome cause is arterial thrombosis. This will often be a delayed diagnosis and the rate of graft loss is high.
Lymphocele
Swelling over the graft site is often due to a lymphocele and this is further suggested by the normal renal function. They cause symptoms through mass effect and limb swelling may occur. Treatment is often surgical.
Renal artery thrombosis vs renal vein thrombosis following renal transplant
These may involve the donor vessels, those of the recipient or both. Renal artery thrombosis usually occurs early post transplant, but is uncommon with an incidence of less than 1%. It typically results in graft loss. It usually occurs as a result of a technical problem such a vessel torsion or sub intimal flaps. The usual presenting feature is a sudden cessation of urine output. When suspected, the occlusion is usually well demonstrated with duplex scanning. Ideally immediate surgical re-exploration should occur. Sadly, the graft has usually been lost by this stage and will require graft nephrectomy. Renal vein thrombosis is not as common as arterial graft thrombosis and the usual presenting features include discomfort at the graft site and swelling of the graft associated with loss of urine output. Again, duplex scanning is indicated. Unfortunately, this complication is also associated with a high incidence of graft loss.
Urological complications of renal transplant
Urinary tract complications manifesting as leakage or obstruction are common complications following renal transplantation and occur in up to 10% of patients. The main underlying cause is the relatively poor blood supply to the transplanted ureter. Patients typically present relatively early in the first 5 weeks following transplantation with pain and swelling at the graft site. Imaging with USS is often the initial test. Therapeutic options include surgical re-implantation of the ureter for large leaks and stent insertion and nephrostomy placement for smaller leaks.
Occurs within minutes of clamp release
Due to pre formed antibodies
Immediate loss of graft occurs
Hyperacute
Occurs in first few days following surgery
Involved both cellular and antibody mediated injury
Pre-sensitisation of the donor is a common cause
Accelerated acute
Traditionally the most common type of rejection
Seen days to weeks after surgery
Predominantly a cell mediated process mediated by lymphocytes
Organ biopsy demonstrates cellular infiltrates and graft cell apoptosis
Acute
Increasingly common problem
Typically; graft atrophy and atherosclerosis are seen. Fibrosis often occurs as a late event
Chronic
Your consultant decides to perform an open inguinal hernia repair under local anaesthesia. Which of the following dermatomal levels will require blockade?
T10
T12
T11
S1
S2
T12
If a sample is normally distributed which of the following is true?
Mean = standard deviation
Mean = standard error of the mean
Mean = median
Mean = variance
The mode and standard error of the mean have the same value
In a normally distributed sample, the mean, median and mode are the same.
Theme: Use of suture materials and closure devices
A.Silk 3/0
B.Polyglactin 3/0
C.Polydioxanone 1/0
D.Stainless steel skin clips
E.Stainless steel wire 1/0
F.6/0 Polypropylene
G.3/0 Undyed polyglactin
H.Polypropylene 3/0
Please select the most appropriate suture material for the situation described. Each option may be used once, more than once or not at all.
35.Mass closure of abdominal wall following elective right hemicolectomy through a midline incision.
Closure of the sternum following coronary artery bypass grafting.
Application of vein patch to femoral artery following endarterectomy.
- Polydioxanone 1/0
PDS or polydioxanone is the ideal suture material. Non absorbable sutures have higher incidence of incisional herniae.
2. Stainless steel wire 1/0
Stainless steel wire is typically used.
3. The correct answer is 6/0 Polypropylene
Polypropylene is the suture of choice. Fine sutures are preferred.
Suture material:
Classification:
Silk
Braided biological
Suture material:
Classification:
Catgut
Braided biological
Suture material:
Classification:
Chromic catgut
Braided biological
A 45 year old lady develops severe back pain and on examination is found to have clinical evidence of an L5/ S1 radiculopathy. Her symptoms deteriorate and eventually a laminectomy is performed. During a posterior surgical approach the surgeons encounter a tough ligamentous structure lying anterior to the spinous processes. This structure is most likely to be the
Transverse spinal ligament
Supraspinal ligament
Anterior longitudinal ligament
Ligamentum flavum
Posterior longitudinal ligament
Ligamentum flavum
Ansa cervicalis
Superior root: Branch of C1 anterolateral to carotid sheath
Inferior root: Derived from C2 and C3 roots, passes posterolateral to the internal jugular vein (may lie either deep or superficial to it)
Innervation:
Sternohyoid
Sternothyroid
Omohyoid
A 22 year old falls over and lands on a shard of glass. It penetrates the palmar aspect of his hand, immediately lateral to the pisiform bone. Which of the following structures is most likely to be injured?
Palmar cutaneous branch of the median nerve
Lateral tendons of flexor digitorum superficialis
Ulnar artery
Flexor carpi radialis tendons
Lateral tendons of flexor digitorum profundus
The ulnar nerve and artery are at most immediate risk in this injury. This is illustrated in the image below
A 46 year old lady presents with symptoms of diarrhoea, weight loss of 10 Kg and a skin rash of erythematous blisters involving the abdomen and buttocks. The blisters have an irregular border and both intact and ruptured vesicles. What is the most likely diagnosis?
Colonic adenocarcinoma
Pancreatic adenocarcinoma
Tropical sprue
Glucagonoma
Insulinoma
Glucagonoma is strongly associated with necrolytic migratory erythema.
Venous drainage of right adrenal
Via one central vein directly into IVC
Venous drainage of the left adrenal
Via one central vein into the LRV
Usually develop over a few months in children
May be pink or red in colour, most common on face and legs
May grow up to 1cm and growth can be rapid, this usually results in excision
Spitz naevus
Ano-rectal advancement flaps
This procedure is primarily directed at high fistulae, and is considered attractive as a sphincter saving operation. The procedure is performed either with the patient in the prone jack knife position or in lithotomy (depending upon the site of the fistula). The dissection is commenced in the sub mucosal plane (which may be infiltrated with dilute adrenaline solution to ease dissection). The dissection is continued into healthy proximal tissue. This is brought down and sutured over the defect.
Follow up of patients with cryptoglandular fistulas treated with advancement flaps shows a success in up to 80% patients[12-14]. With most recurrences occurring in the first 6 months following surgery[12]. Continence was affected in some patients, with up to 10% describing major continence issues post operatively.
A 63 year old man is undergoing a coronary artery bypass procedure. During the median sternotomy which structure would routinely require division?
Parietal pleura
Interclavicular ligament
Internal mammary artery
Brachiocephalic vein
Left vagus nerve
The interclavicular ligament lies at the upper end of a median sternotomy and is routinely divided to provide access. The pleural reflections are often encountered and should not be intentionally divided, if they are, then a chest drain will need to be inserted on the affected side as collections may then accumulate in the pleural cavity. Other structures encountered include the pectoralis major muscles, again if the incision is truly midline then these should not require formal division. The close relationship of the brachiocephalic vein should be borne in mind and it should be avoided, iatrogenic injury to this structure will result in considerable haemorrhage.
The vertebral artery traverses all of the following except?
Transverse process of C6
Transverse process of the axis
Vertebral canal
Foramen magnum
Intervertebral foramen
The vertebral artery passes through the foramina which are located in the transverse processes of the cervical vertebra, it does not traverse the intervertebral foramen.
What are the four regions of the vertebral artery
The first part runs to the foramen in the transverse process of C6. Anterior to this part lies the vertebral and internal jugular veins. On the left side the thoracic duct is also an anterior relation.
The second part runs superiorly through the foramina of the the transverse processes of the upper 6 cervical vertebrae. Once it has passed through the transverse process of the axis it then turns superolaterally to the atlas. It is accompanied by a venous plexus and the inferior cervical sympathetic ganglion.
The third part runs posteromedially on the lateral mass of the atlas. It enters the sub occipital triangle, in the groove of the upper surface of the posterior arch of the atlas. It then passes anterior to the edge of the posterior atlanto-occipital membrane to enter the vertebral canal.
The fourth part passes through the spinal dura and arachnoid, running superiorly and anteriorly at the lateral aspect of the medulla oblongata. At the lower border of the pons it unites to form the basilar artery.
McKeown oesophagectomy
More proximal lesions will require a total oesphagectomy (Mckeown type) with anastomosis to the cervical oesophagus.
Which of the following statements relating to quadratus lumborum is false?
Causes flexion of the thoracic spine
Causes the rib cage to be pulled down
Innervated by anterior primary rami of T12 and L1-3
Attached to the iliac crest
Inserts into the 12th rib
Quadratus lumborum
Origin: Medial aspect of iliac crest and iliolumbar ligament
Insertion: 12th rib
Action: Pulls the rib cage inferiorly. Lateral flexion.
Nerve supply: Anterior primary rami of T12 and L1-3
The rectus abdominis causes flexion of the thoracic spine and therefore the statement suggesting that quaratus lumborum does so is incorrect.
Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.
Failure of maturation of collagen in all the connective tissues.
Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.
Osteogenesis imperfecta
Salter Harris Classification
SALT-C
Straight: through physis
Above: through physis and metaphysis
Lower: through physis and epiphysis to include the joint
Through: fracutre involving physis, metaphysis and epiphysis
Crush: Crush injury involving physis (may resemble Type 1)
Which muscle does not insert on the medial surface of the greater trochanter?
Gemelli
Obturator internus
Piriformis
Quadratus femoris
Obturator externus
The quadratus femoris fibres pass laterally to be inserted into the quadrate tubercle on the intertrochanteric crest of the femur. The other muscles all insert on the trochanteric fossa lying medial to the greater trochanter.
Ligaments of the cervical spine
